Dining with Diabetes Down EastA Program for People with Diabetes
and Their Families

This program is free and open to anyone with type 2 diabetes, prediabetes, family members and caregivers. Participants will learn how to select and prepare foods that help to control blood sugar, cholesterol and blood pressure. There will be an opportunity to taste a variety of main dishes, side dishes, and desserts.

If you are interested in participating in this program, please answer the following questions so we may offer it in a way that best fits your needs.

Your answers will be confidential.

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1.Please provide the following contact information:

Name:

Address:

City/Town:

ZIP:

Email Address:

Phone Number:

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2.How old are you?

Years of age:

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3.How many of your family members and/or caregivers do you think will join you?

None, I'll participate alone.

1

2

3

I'm not sure at this time.

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4.Please select from the list below what you or a family member have been told by a medical provider:

I have Type 2 Diabetes.

I have Adult Onset Diabetes.

I have Pre-Diabetes.

I have Type 1 Diabetes.

I have Juvenile Onset Diabetes.

I'm not sure what type of diabetes I have.

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5.The group will meet once per week for 4 weeks. Please select from the list below the times for which you would attend.

On a weekday from 10:00 a.m. to 12:00 noon

On a weekday from 1:00 p.m. to 3:00 p.m.

On a weekday from 3:00 p.m. to 5:00 p.m.

On a weekday from 6:00 p.m. to 8:00 p.m.

On Saturdays from 10:00 a.m. to 12:00 p.m.

On Saturdays from 1:00 p.m. to 3:00 p.m.

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6.Please select the towns for which it would be most convenient to hold the program.

Indian Township

Princeton

Baileyville

Calais

Pleasant Point

Eastport

Lubec

Trescott

Machias

Harrington

Cherryfield

Columbia

Milbridge

Other

Town Name

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7.Optional: Please list any specific locations (buildings) located near you that may be appropriate for holding the program. Those with cooking facilities are preferred but not required.

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8.Optional: Please describe any topics that you would like to learn about.

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9.Optional: Please describe anything that could possibly interfere with your ability to participate in all 4 sessions of the series.

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10.Are you willing to make a commitment to attending all 4 weekly sessions of the series?